Steptherapyprotocols coh.doc

STEP THERAPY GUIDELINES FOR THE CITY OF HOUSTON (COH) EMPLOYEES
Effective May 1 2005, the City of Houston implemented a Step Therapy Program for their employees for the following therapies: Cox 2, Leukotriene Inhibitors, Rheumatoid Arthritis/Psoriasis agents, Ace Inhibitor (ACEI) and Angiotensin Receptor Blocker (ARB). The Step Therapy guidelines are as follows: Cox- 2 Inhibitor Step Therapy Criteria: Celebrex

Celebrex To receive a Cox 2 drug, you must have evidence of one of the following protocols in the p ast 120 days:
One prescription for a glucocorticoid (i.e., prednisone); or
b. One prescription for Coumadin (warfarin); or c. One prescription for a proton pump inhibitor (i.e., Nexium, Protonix, Prevacid), H2-receptor antagonist (i.e.,
Zantac), sucralfate, AND one non-selective NSAID (i.e., naproxen, ibuprofen), or
Leukotriene Modifier Step Therapy: Accolate, Singulair, Zyflo, Zyflo CR

Accolate, Zyflo, Zyflo CRFor a prescription of Accolate, Zyflo, Zylfo CR to pay automatically, you must meet the following criteria :
a. < 12 years of age does not require step therapy b. > 12 years of age must have a previous trial of an inhaled corticosteroid (i.e., Flovent) or a combination inhaled
corticosteroid product in the previous 60 days
**Accolate 10mg tablets are excluded from the ST edit because these dosage forms are most likely used to treat childre n less than 12 years of age** Singulair The criteria for a prescription of Singulair 10 mg tablets to pay automatically are as follows:
a. < 15 years of age does not require step therapy b. >15 years of age a previous trial of either an inhaled corticosteroid or a combination inhaled corticosteroid (i.e.
Pulmicort), or a nasal corticosteroid (i.e. Flonase), or a prescription for a non-sedating antihistamine/decongestant combination product (i.e., Allegra) in the previous 60 days.
Rheumatoid Arthritis/ Psoriasis Step Therapy: Enbrel, Humira, Kineret, Raptiva

Enbrel
• A prescription for Enbrel will pay automatically if you have taken a topical or oral psoriasis medication in the past
180 days. Topical and oral psoriasis d rugs include:
• A previous claim for another biologic DMARD indicated for the same indications (abatacept, adalimumab,
alefacept, anakinra, efalizumab, infliximab, or rituximab) with a days supply that overlaps into the 180 day look back time frame AND there has been a minimum of 30 days between the apparent end of the previous biologic DMARD therapy and the new claim.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
• A previous claim for injectable or oral methotre xate with a days supply that overlaps into 180 days prior to the
• A previous claim for the identical biological DMARD within 90 days prior to the new claim. The claims system is
designed to identify an etanercept claim with a days supply that ends within the 90 day look back parameter.
**The claim will be rejected for payment if there is a claim in the patient’s medication history for ANY other biologic DMARD (see above examples) regardless of indication, with a days supply that overlaps into the previous 30 days**Humira In order for a claim for adalimumab to pay automatically, the patient must have a medication history of one of the following:
• A previous claim for injectable or oral methotrexate with a days supply that overlaps into 180 days prior to the
• A previous claim for a topical or systemic psoriasis treatment in their medication history with a days supply that
overlaps into the past 180 days (six months). Topical treatments that will allow automatic payment for adalimumab include coal tar products, anthralin, topical corticosteroids, calcipotriene, and tazarotene. Systemic treatments include methotrexate, cyclosporine, acitretin, or methoxsalen.
• A previous claim for a conventional therapy for Crohn’s disease with a days supply that overlaps into the previous
180 days including aminosalicylates, sulfasalazine, budesonide, methotrexate, azathioprine, 6-mercaptopurine, or cyclosporine.
• A previous claim for another biologic DMARD indicated for the same indications (abatacept, alefacept, anakinra,
efalizumab, etanercept, infliximab, or rituximab) with a days supply that overlaps into the 180 days (six-month) look-back time frame AND there has been a minimum of 30 days between the apparent end of the previous biologic DMARD therapy and the new claim.
• A previous claim for the identical biological DMARD within 90 days prior to the new claim. The claims system is
designed to identify an adalimumab claim with a days supply that ends within the 90-day look-back parameter.
**The claim will be rejected for payment if there is a claim in the patient’s medication history for ANY other biologic DMARD (abatacept, alefacept, anakinra, efalizumab, etanercept, infliximab, or rituximab), regardless of indication, with a days supply that overlaps into the previous 30 days.**
Kineret In order for a claim for anakinra to pay automatically, the patient must have a medication history of one of the following:
• A previous claim for injectable or oral methotrexate with a days supply that overlaps into 180 days prior to the
• A previous claim for use of another biological DMARD labeled for rheumatoid arthritis (abatacept, adalimumab,
etanercept, infliximab, or rituximab) with a days supply that overlaps into the 180 day look-back time frame AND there has been a minimum of 30 days between the apparent end of the previous biologic DMARD therapy and the new claim.
• A previous claim for the identical biological DMARD within 90 days prior to the new claim. The claims system is
designed to identify an anakinra claim with a days supply that ends within the 90-day look-back parameter.
**The claim will be rejected for payment if there is a claim in the patient’s medication history for ANY biologic DMARD other than requested drug (abatacept, adalimumab, alefacept, efalizumab, etanercept, infliximab, or rituximab, but excluding the requested drug), regardless of indication, with a days supply that overlaps into the previous 30 days.**
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Raptiva In order for an efa lizumab claim to pay automatically the patient must have a medication history of one of the following:
• A previous claim for a topical or systemic psoriasis treatment in their medication history with a days supply that
overlaps into the past 180 days (six months). Topical treatments that will allow automatic payment for efalizumab include coal tar products, anthralin, topical corticosteroids, calcipotriene, and tazarotene. Systemic treatments include methotrexate, cyclosporine, acitretin, or methoxsalen.
• A previous claim for use of another biological DMARD indicated for psoriasis (adalimumab, alefacept,
etanercept, or infliximab) with a days supply that overlaps into the 180 days (six-month) look-back time frame AND there has been a minimum of 30 days between the apparent end of the previous biologic DMARD therapy and the new claim.
• A previous claim for the identical biological DMARD within 90 days prior to the new claim. The claims system
is designed to identify an efalizumab claim with a days supply that ends within the 90-day look-back parameter.
**The claim will be rejected for payment if there is a claim in the patient’s medication history for ANY biologic DMARD other than requested drug (abatacept, adalimumab, alefacept, anakinra, etanercept, infliximab, or rituximab, but excluding the requested drug), regardless of indication, with a days supply that overlaps into the previous 30 days**

The Angiotensin Converting Enzyme Inhibitor (ACEI) Edit All prescriptions written for a generic ACEI (lisinopril, captopril, enalapril, benazepril, fosinopril, moexipril, trandolapril, or quinapril) or for a generic ACEI/diuretic combination will automatically pay. There are no restrictions on these agents. Currently, there are only two brand ACEIs that are not available generically (Altace and Aceon). Prescriptions written for brand ACEIs or brand ACEI/diuretic combinations will automatically pay if the patient’s medication history indicates use of the identical brand drug in the previous 90 days. The claims system with identify and count any brand ACEI or brand ACEI/diuretic with a days supply that ends within the 90 days prior to the new claim. The edit will allow for automatic payment of a new claim if the history ACEI is a brand ACEI and the new claim is for same ACEI with diuretic. If the history drug is a brand ACEI/diuretic and the new claim is the identical ACEI without diuretic, the claim will also automatically pay. If these requirements are not met a Point of Sale Message will be returned to the pharmacy stating that step therapy criteria was not met and that a PA approval is necessary. The Angiotensin II Receptor Antagonist (ARB) Edit à ( Atacand, Atacand HCT, Avapro, Avalide, Benicar, Benicar HCT, Cozaar, Hyzaar, Diovan, Diovan HCT, Micardis, Micardis HCT, Teveten, Teveten HCT) New prescriptions written for an ARB or ARB/diuretic combination will automatically pay if there is a history of the same ARB or ARB/diuretic combination found in the patient’s medication history within the past 90 days. The claims system will identify and count any ARB or ARB/diuretic with a days supply that ends within the 90 days prior to the new claim. New claims for an ARB or ARB/diuretic will also automatically pay if the patient’s medication history contains evidence of a brand or generic ACEI or brand or generic ACEI/diuretic with a days supply that ends within the previous 365 day look-back period. If these claims are not found, a Point of Sale M essage will be returned to the pharmacy stating that step therapy criteria was not met and that a PA approval is necessary. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association